When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Compare muscle strength bilaterally.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client's heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.

Choice B reason: This is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client's renal function and fluid balance, but these are not the priority assessments.

Choice C reason: This is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client's neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.

Choice D reason: This is another incorrect intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client's reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.

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Correct Answer is B

Explanation

Choice A reason: Serum potassium and sodium levels are not relevant to the assessment of the wound infection. They are electrolytes that regulate fluid balance, nerve conduction, and muscle contraction. They may be affected by dehydration, renal failure, or diuretics.

Choice B reason: Neutrophil count is the most relevant laboratory value to note before reporting the wound infection. Neutrophils are white blood cells that fight bacterial infections and inflammation. A high neutrophil count indicates an acute infection or inflammation, while a low neutrophil count indicates a compromised immune system or a chronic infection.

Choice C reason: Blood pH level is not relevant to the assessment of the wound infection. It is a measure of the acidity or alkalinity of the blood. It may be affected by respiratory or metabolic disorders, such as acidosis or alkalosis.

Choice D reason: Hematocrit is not relevant to the assessment of the wound infection. It is the percentage of red blood cells in the blood. It may be affected by anemia, dehydration, or polycythemia.

A. Smoking cessation. B. Regular exercise. C. Low-fat diet. D. Stress reduction.

Correct Answer is A

Explanation

Choice A reason: Smoking cessation is the most important lifestyle modification for the nurse to encourage. Smoking is a major risk factor for cardiac disease, as it increases blood pressure, heart rate, and oxygen demand, and damages the blood vessels and the heart muscle. Quitting smoking can reduce the risk of cardiac disease by 50% within one year.

Choice B reason: Regular exercise is a beneficial lifestyle modification for the nurse to encourage, but not the most important one. Exercise can improve cardiovascular fitness, lower blood pressure, and reduce body weight, but it does not eliminate the harmful effects of smoking on the heart and blood vessels.

Choice C reason: A low-fat diet is a helpful lifestyle modification for the nurse to encourage, but not the most important one. A low-fat diet can lower cholesterol levels and prevent atherosclerosis, but it does not reverse the damage caused by smoking to the heart and blood vessels.

Choice D reason: Stress reduction is a useful lifestyle modification for the nurse to encourage, but not the most important one. Stress can trigger the release of hormones that increase blood pressure, heart rate, and oxygen demand, and can also lead to unhealthy behaviors such as smoking, overeating, and alcohol abuse. However, stress reduction alone does not address the direct effects of smoking on the heart and blood vessels.

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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

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